Thenar hammer syndrome in a wrestler

and circulation. In severe circumferential chest burn with impending or established respiratory compromise, escharotomy is considered as an emergency intervention. Chest wall escharotomy is a form of decompressive therapy by cutting the skin eschar to the depth of subcutaneous fat. This superficial incision releases the eschar, decompresses the restriction on chest wall expansion and allows adequate ventilation. An adequate escharotomy should lead to clinically meaningful improvement in ventilatory status of the patient. Even though emergency chest escharotomy is considered as a potentially lifesaving procedure, the demographic reports demonstrate it is a relatively uncommon procedure performed in the emergency setting at the time of initial presentation of severely burned patient. Kupas et al. reported two case series with circumferential chest burn that underwent chest escharotomies in out-ofhospital setting, with significant improvement in patient ventilation after the interventions. In our case, despite early endotracheal intubation, the patient remained hypoxemic with significant reduction in ventilatory compliance. Furthermore, the patient’s chest wall movement is severely restricted with high ventilator pressures and marked reduction of desired tidal volume. Undoubtedly, the need for timely escharotomy procedure by an experienced provider remains imperative in the care of severely burned patients. An immediate improvement in chest wall expansion and ventilation proved the importance of emergency escharotomy in cannot oxygenate and cannot ventilate situation in mechanically ventilated circumferential chest burn patient. Patients with circumferential chest burns are at risk of significant risk respiratory compromise. Emergency chest escharotomy is a rare procedure in burn treatment protocol in ED. However, it is considered as lifesaving procedure when faced with difficult ventilation in a circumferential chest burn in mechanical ventilated patient.

stabilisation of airway, breathing and circulation. In severe circumferential chest burn with impending or established respiratory compromise, escharotomy is considered as an emergency intervention. Chest wall escharotomy is a form of decompressive therapy by cutting the skin eschar to the depth of subcutaneous fat. 6 This superficial incision releases the eschar, decompresses the restriction on chest wall expansion and allows adequate ventilation. 3,5 An adequate escharotomy should lead to clinically meaningful improvement in ventilatory status of the patient.
Even though emergency chest escharotomy is considered as a potentially lifesaving procedure, the demographic reports demonstrate it is a relatively uncommon procedure performed in the emergency setting at the time of initial presentation of severely burned patient. Kupas et al. reported two case series with circumferential chest burn that underwent chest escharotomies in out-ofhospital setting, with significant improvement in patient ventilation after the interventions. 5 In our case, despite early endotracheal intubation, the patient remained hypoxemic with significant reduction in ventilatory compliance. Furthermore, the patient's chest wall movement is severely restricted with high ventilator pressures and marked reduction of desired tidal volume. Undoubtedly, the need for timely escharotomy procedure by an experienced provider remains imperative in the care of severely burned patients. An immediate improvement in chest wall expansion and ventilation proved the importance of emergency escharotomy in cannot oxygenate and cannot ventilate situation in mechanically ventilated circumferential chest burn patient.
Patients with circumferential chest burns are at risk of significant risk respiratory compromise. Emergency chest escharotomy is a rare procedure in burn treatment protocol in ED. However, it is considered as lifesaving procedure when faced with difficult ventilation in a circumferential chest burn in mechanical ventilated patient.

Competing interests
None declared.

Data availability statement
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Thenar hammer syndrome in a wrestler Dear Editor, A 35-year-old man presented to the ED with acute onset Reynaud's phenomenon, paraesthesias and pain affecting the right thumb (Fig. 1). The patient was a non-smoker and had no personal or family history of autoimmune or prothrombotic disorders. His remaining medical history was unremarkable. The man denied any acute trauma to his hand or wrist; however, recreationally was involved in wrestling matches, competing in over 100 matches across the past 5 years. During matches, he would often be picked up and slammed by opponents, breaking his fall with the palms of his hands. On examination, brachial and radial pulses were strong and regular bilaterally; however, capillary refill time was 6 s on the right thumb. Identifying these features as a possible vascular emergency, the case was discussed with the nearest vascular surgery department. A heparin infusion was commenced and transfer of care under vascular surgery expedited. In the interim, CT angiogram from the aortic arch to the extremities was conducted and revealed a 10 mm thrombus in the proximal segment of the radial sided deep palmar arch adjacent to the trapezium, in keeping with thenar hammer syndrome. Collateral filling of the remaining deep palmar arch, princeps pollicis and digital arteries were via the ulnar artery.
Symptoms resolved over the next 48 h without requiring surgery. An extensive panel to investigate prothrombotic disorders or autoimmune disease was negative, apart from being heterozygous for the Factor V Leiden variant. Outpatient echocardiogram and Holter monitor were also unremarkable.
Thenar hammer syndrome is a rare presentation in which the distal radial artery is damaged by trauma, resulting in intimal injury, thrombosis and aneurysm formation of the radial artery. Presenting symptoms are consistent with digital ischaemia of the thumb or index fingerparaesthesias, blanching or Reynaud's phenomenon and necrotic digital ulcers. As the name suggests, this syndrome is typically associated with occupations involving tasks that repeatedly use the palm of the hand as a hammer. As such, thenar hammer syndrome has been reported in construction workers such as tilers or machinists 1,2 and is also reported through long-term use of vibrating hand-held power tools. 3 In these occupations, the deep branch of the radial artery is at risk of mechanical trauma where it crosses directly over the dorsal ridge of the trapezium. Although located dorsally at this point, the radial artery is susceptible to compressive forces against the trapezium transmitted through pounding of the thenar eminence.
In this case, the history of repetitive mechanical trauma, lack of thromboembolic risk factors and the location of the thrombus adjacent to the trapezium support the diagnosis of thenar hammer syndrome. Rather than being associated with a typical occupation however, the trauma appears to be in the unique form of wrestling manoeuvres, whereby the patient would break his fall when being slammed from heights with outstretched pronated hands. It is unclear whether heterozygosity for Factor V Leiden contributed with mixed evidence regarding a role in arterial thrombosis.
Although thenar hammer syndrome is a rare presentation, the principles of a suspected vascular emergency apply early vascular surgery referral is the cornerstone of management for the emergency physician and should not be delayed by pending diagnostic investigations.

Author contributions
NDMHhistory taking and examination of patient, write manuscript, obtain supporting clinical images. FJhistory taking and examination of patient, consent process, revision of manuscript.